Provider Demographics
NPI:1699888008
Name:PEGRAM, GEORGE VERNON III (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:VERNON
Last Name:PEGRAM
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 WRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1181
Mailing Address - Country:US
Mailing Address - Phone:865-213-8401
Mailing Address - Fax:865-213-8596
Practice Address - Street 1:304 WRIGHT ST
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-1181
Practice Address - Country:US
Practice Address - Phone:865-213-8401
Practice Address - Fax:865-213-8596
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL21971207V00000X
TNMD55106207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN6087267OtherBLUE CROSS BLUE SHIELD
AL51046869OtherBLUE CROSS BLUE SHIELD
AL009918220Medicaid
TNQ026242Medicaid